Dr. Greta Cummings
Greta Cummings never planned on her career taking the direction it did.
When Cummings began her clinical nursing practice in 1979, she was directly responsible for the care of eight patients. Within a few years, she was supervising the care of 35 patients as a nursing manager, and soon after was overseeing the care of more than 250 patients as director of nursing at the University of Alberta Hospital.
Today, Cummings is nationally and internationally recognized for both her leadership in nursing and her research of leadership styles.
"In each role I undertook, my motivation was to provide the best care possible to each and every single patient - being a leader was never my goal," she said.
A defining moment
Cummings credits a heartbreaking encounter with a patient as a pivotal point in her life and career. It showed she could make a difference in patient care and influence the system.
"We had a patient with us for a year and a half whose tracheostomy procedure was completed incorrectly," she explained. "His tubes didn't fit properly, which meant that his tracheostomy tube had to be changed in the operating room each time, rather than on the ward."
At the time, Cummings was the nursing manager and was on the ward every single day. "Most of his physicians and care team would change every couple of weeks; in addition to his wife, the nursing staff, really, were the only constant in his life."
The patient couldn't speak due to his tracheostomy, but would write notes to communicate and Cummings got to know him quite well.
"After months of issues and trying to get him stable, he wrote me a note one day," said Cummings. "He said that he did not want any more procedures. He didn't want to go to the operating room anymore. He had had it with all the procedures."
" I've only told this story to one other person, but it was a turning point for me." - Greta Cummings
Later that night, afterhours, medical staff took the patient to the operating room and changed his tube. There were issues with the procedure.
"The next morning when I came on, he wrote me a note," said Cummings, fighting back tears. "He said, 'Kill me,' because the staff had gone against his wishes. "
Cummings was livid. "I tracked down both the surgeon who performed the procedure and the chairman of medicine, and pulled them both out of their meetings. I told them that from now on, absolutely no one was going to touch this man unless I gave consent. They were going to put one physician in charge to look after the patient for the rest of the time that he was in the hospital. They were going to help with discharge planning so that we could get him moved and all that was going to happen today."
She readily admits that she could have been fired that day; but she wasn't. The surgeon apologized to the patient, who was assigned a single physician for the rest of his stay.
"I've only told this story to one other person, but it was a turning point for me," said Cummings.
"This entire situation - doing the right thing, standing up and advocating for the patient - told me that I could be a leader. I could change the system, and it didn't matter if I was breaking the rules or not."
Leading the way
Over the next decade, Cummings interest in leadership expanded to include a breadth of leadership styles.
"I was director of nursing during the Ralph Klein-era cutbacks in Alberta and ended up leading quite a few rounds of hospital and regional restructuring," she said. "I had to lay off thousands of nurses and managers over multiple rounds of restructuring in the 1990s - one time we had to cut 25 per cent of the budget overnight, which hit the nursing positions particularly hard."
When Cummings began her PhD studies, she wanted to determine the effects the layoffs and restructuring had on nurses.
"The impacts were quite substantial to nurse's health, to their relationship with their work and to their own job and career satisfaction," she said. "They stopped seeing their nursing career as a mission or a calling, but as a job."
Cummings' research also found that there were differences in how nurses fared after being laid off, based on how they saw their managers and directors leadership style.
"Resonant leaders are high in emotional intelligence - they care about other people, they establish open and transparent relationships with their staff and with others. These leaders promote their staff, develop them and have an interest in key outcomes for their staff and for their patients.
"Dissonant leaders operate more on the authoritative side of leadership, an 'it's my way or the highway' attitude. They maintain a greater distance, both social and emotional, from their employees and don't take into consideration that their success is actually due to other people."
Cummings found that nurses who worked for resonant leaders had higher job satisfaction, less emotional exhaustion, and were better able to attend to their patients' care needs. Nurses who worked for dissonant leaders had low job satisfaction, high emotional exhaustion, and were not able to tend to patient care needs.
"Leadership in the healthcare system is very important," said Cummings, "But I don't think there has been enough research to show its impact. There is a general understanding that everyone in a management role is a leader and is providing appropriate leadership. I don't think that's true."
In 2013 Cummings completed a systematic review on the relationship between leadership and patient outcomes. "Every study showed the same kinds of transformation. Relational leadership - which emphasizes purpose, inclusion, empowerment, ethics and process - leads to fewer adverse events, higher patient satisfaction, fewer complications and lower mortality."
Cummings also examined resonant leadership styles versus dissonant leadership styles in Alberta hospitals, and was surprised by the results.
"After testing for all of the factors that lead to patient mortality - including health issues, gender, high risk behavior, and any other factors that influence mortality - resonant leadership contributed to six per cent of the variance in mortality and was the only leadership style that significantly reduced patient mortality. Six per cent. Leadership styles do make a difference to patient outcomes."
Another objective of Cummings' research is to examine how effective leadership styles can be developed in the healthcare system's current and aspiring leaders.
"Resonant leadership isn't just about being the nice person," said Cummings. "It's really about having values-based conversations to help people develop their own leadership skills."
How can this be done? According to Cummings, the key to developing leadership is self-awareness. "How are you as a leader? What drives you? What are your emotions and values? I think we all know that there is broad spectrum of self-awareness and not everyone realizes how they come across - which is one of the issues in developing leadership skills."
Cummings admits that it isn't easy to learn effective leadership styles. "The best leadership development programs start with learning how to lead yourself, and can be very emotionally intensive.
"You must spend time looking inward to see how you behave and how you respond to particular situations. It can be painful to see how you come across; but that's the turning point, that's the beginning of growth and seeing where you can improve your own behaviours."
You can only lead your team and your organization if you're able to lead yourself. "And there's always room to grow and improve," said Cummings with a laugh.
Striking a chord
Cummings, who was recently inducted into the Sigma Theta Tau International Nursing Hall of Fame, believes that her research is resonating with people at all levels of the healthcare system.
She was named one of the world's most influential researchers in the 2014 Highly Cited Researchers list, compiled by Thomson Reuters, and sees this as in indicator that her research has identified a clear gap, not just in knowledge, but also practice.
"Nurses need to have an impact on the system," she said. "The research evidence shows they can - especially on patient outcomes."
Despite the change in Canada's healthcare system since Cummings was caring for her tracheostomy patient many years ago, does she believe today's nurses can still advocate for their patients and have an impact like she did all those years ago?
"Absolutely they can," she said, eyes blazing. "And I hope that it happens a lot."